Cardiology Coding Alert

Not sure how modifiers GA and GZ differ? Issuing the ABN is the key.

Distinguishing the modifiers related to an Advance Beneficiary Notice (ABN) is a tricky business, but it’s not one you can ignore.

To clear up any modifier confusion your practice might have, check out this quick primer on when to use each modifier, and whether or not it requires an ABN.

GA Clears the Way to Bill Patient

According to Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida, you must issue the ABN when Medicare might not cover an item or service, including when Medicare may not consider the item or service medically reasonable and necessary for a specific patient in a particular instance.

In these situations, the payer expects you to append one of the following modifiers to the CPT^® code you are reporting for the service:

• GA (Waiver of liability statement issued as required by payer policy, individual case): “Use this modifier when you issue a mandatory ABN for a service as required, and [the ABN] is on file,” Verno explains. You don’t need to submit the ABN on GA claims, but you should have it available upon request, Verno says.

• GX (Notice of liability issued, voluntary under payer policy): “Use this modifier when you issue a voluntary ABN for a service Medicare never covers because it is statutorily excluded, or is not a Medicare benefit,” says Verno. In certain situations, you can also use this modifier in combination with modifier GY (see below). 

• GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit): “Use this modifier to report that Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit,” explains Verno. In certain situations, you can also use this modifier in combination with modifier GX.

• GZ (Item or service expected to be denied as not reasonable and necessary): “Use this modifier when you expect Medicare to deny payment of the item or service due to a lack of medical necessity, and no ABN was issued,” says Verno.

Example: In your cardiologist’s opinion, a Medicare patient requires transthoracic echocardiography to assist with diagnosis. However, the patient’s record does not support reporting any of the codes indicating medical necessity listed in the payer’s local coverage determination for the test. You issue the patient a standard CMS ABN to allow her to make an informed decision about having a service Medicare is unlikely to consider medically necessary. You keep a copy of the ABN in the patient’s record and give her a copy of the signed form. You submit a claim for the service with modifier GA appended to the test code.

Include Modifiers to Stay in the ‘Norm’

Despite Medicare’s insistence on using the above modifiers when appropriate, some coders might wonder why they’re necessary at all.

The reason: “The modifiers don’t affect … whether or not a claim is actually paid,” explains Leslie Johnson, CPC, CSFAC, chief coding officer at PRN Advisors in Palm Coast, Fla. Though payment might not be affected, Johnson recommends using the modifiers whenever Medicare requires it — or you could be identified as an outlier.

“Rules are rules. CMS is tracking every single code, and that includes the modifiers. Codes that are reported — or not reported — are indicative of patterns that are tracked by the data-mining systems,” Johnson explains. This means that if you’re not using the modifiers, you could attract the attention of Medicare auditors; further, you won’t be able to bill the patient for the service.

Bottom line: Deviate from the norm one way or another, and payers could take notice, Johnson warns.